HIPAA AUTHORIZATION – ASSIGNMENT OF BENEFITS

I consent to treatment in accordance with my doctor’s prescription.

I authorize Orthotics & Prosthetics Services and its affiliates to use and disclose my protected health information (PHI) for purposes of treatment, payment, and healthcare operations. Also, to release necessary medical information to my insurance carrier(s) to process my medical claim. I authorize my insurance carrier to pay benefits directly to Orthotics & Prosthetics Services and its affiliates. I request that payment of authorized Medicare, Medicaid, or private insurance benefits be made payable to Orthotics & Prosthetics Services and its affiliates for any covered services. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents in order to determine these benefits or benefits for related services.

I understand and agree that:

• My information may be shared with physicians, insurance companies, and other healthcare providers as needed
• I have the right to revoke this authorization at any time in writing
• I am responsible for the following expenses: any service my insurance plan deems "non-covered", all coinsurance and/ or co-payment amounts, all deductibles, any amount that exceeds benefit limits under my insurance plan and any amount my insurance plan deems not covered because I was not insured on the date of service.